Provider Demographics
NPI:1649559378
Name:DAUGHERTY, MAUREEN ANN (MA)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:ANN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3361 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2624
Mailing Address - Country:US
Mailing Address - Phone:612-644-6373
Mailing Address - Fax:
Practice Address - Street 1:3361 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2624
Practice Address - Country:US
Practice Address - Phone:612-644-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist